PROVIDER MANUAL - Sendero Health Plans
PROVIDER MANUAL - Sendero Health Plans
PROVIDER MANUAL - Sendero Health Plans
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<strong>Sendero</strong> Provider Manual Page 43 of 184<br />
5.12 Utilization Decisions<br />
Consistency of Application of UM Criteria<br />
<strong>Sendero</strong> uses Milliman Care Guidelines and InterQual Criteria for all utilization management decisions. The<br />
criteria are applied by utilization and case management staff and by the Medical Director. All preauthorization,<br />
concurrent, and retrospective review decisions as well as appeal determinations will reference the<br />
appropriate medical necessity criteria and indicate why the criteria were met or not met.<br />
Denials<br />
The Medical Director reviews all potential denials related to behavioral health diagnoses. A physician makes<br />
all medical necessity denial determinations for inpatient mental health and chemical dependency partial<br />
hospitalization, and intensive structured outpatient. The Medical Director may contact the provider requesting<br />
services for additional information or to discuss alternatives to care. The provider requesting services may<br />
request to consult with the Medical Director. The Medical Director will make at least two (2) attempts to<br />
contact the Member’s provider regarding a denial. Members and providers receive written notification of all<br />
denials. Denial notifications include the reason for the denial and instructions for requesting an appeal.<br />
Appeals<br />
For more information regarding appeal process, contact Network Management at the phone number below, or<br />
refer to “ST5 Complaints & Appeals” or “CH4 Complaints & Appeals” in this manual.<br />
5.13 Responsibilities of Behavioral <strong>Health</strong> Providers<br />
Behavioral health providers and/or physical health providers, who are treating a behavioral health condition,<br />
are responsible for appropriate referrals to the Texas Department of Protective and Regulatory Services<br />
(TDPRS) for suspected or confirmed cases of abuse.<br />
They are also responsible to assure that any necessary pre-authorization activities take place and for the<br />
following:<br />
Assure the release of information consent form is signed by the Member.<br />
Refer Members with known or suspected physical health problems or disorders to the primary care provider<br />
for examination and treatment.<br />
Only provide physical health if a behavioral health provider is already rendering treatment for behavioral<br />
health conditions.<br />
Ensure that the patients know of, and are able to avail themselves of, their rights to execute Behavioral<br />
<strong>Health</strong> Advance Directives.<br />
Assure All STAR and CHIP Members that receive inpatient psychiatric services are scheduled for<br />
outpatient follow up and/or continuing treatment prior to discharge. The outpatient treatment must occur<br />
within seven (7) days from the date of discharge.<br />
Have policies and procedures in place on how to follow-up on Member missed appointments.<br />
<strong>Sendero</strong> Customer Services 1-855-526-7388 Network Management 1-855-895-0475<br />
<strong>Health</strong> Services Dept.: 1-855-297-9191 (FAX 1-512-275-2862)